The delivery of definitive acute stroke care in Africaremains low due to prehospital barriers, and these are known to be country-specific. There have been no studies on elucidating these barriers in Kenya. Objectives: We sought to identify the nature of barriers to acute stroke care for patients presenting to our hospital in Nairobi, Kenya. Materials and Methods: We conducted a prospective cross-sectional study atour tertiary regional referral center from August 2018 to March 2019 for patients presenting with an acutestroke. We consented participants (patients or their registered next-of-kin) to fill out a questionnaire on their journey from stroke-onset to the ward bed, and about their knowledge about stroke. Results: We recruited 103 participants. Only 25.2% arrived to hospital within 3.5 h (early arrival) of stroke onset. The significant factors causing delay were:distance from hospital, traffic, visiting another hospital first, and lack of transport vehicle. Factors significantly associated ( P<.05) with early arrival were: older age, non-African ethnic origin, bystander present at stroke onset, living near (<15km) the hospital, and knowledge of stroke. Almost 80% believed stress was a major risk factor and that dizziness was a cardinal symptom. Only 50% knew of the availability of thrombolysis/thrombectomy and their roles in stroke treatment, and only 37.9% knew the correct time limits for these. Conclusions: We identified a number of prehospital barriers to reaching hospital on time for definitive stroke treatment, which have implications on the structure of emergency services for stroke in our city. Our study also revealed interesting observations on the public’s understanding about stroke, calling for a tailored public awareness campaign to improve stroke knowledge.

In a patient with Collet‐Sicard syndrome and multiple myeloma, both extramedullary plasmacytomas and internal jugular vein‐sigmoid sinus thrombosis should be considered as they can coexist.

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Background Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of excessive inflammation and tissue destruction due to abnormal immune activation. HLH carries a very high mortality, and while delays in patients’ presentation to hospital, time to suspicion of HLH, investigation, and initiation of therapy all play a part, mortality remains high even with timely diagnosis and treatment. Classical manifestations of HLH include persistent fever, cytopenias, and liver dysfunction. Case presentation We present four cases of secondary HLH, highlighting the demographic and clinical characteristics of these patients, underlying triggers (including systemic lupus erythematosus, lymphoproliferative disorders, and leishmaniasis), together with challenges associated with the diagnosis and treatment of this rare disorder and a brief review of literature. Conclusion HLH has protean manifestations and requires a high index of suspicion as it can be a great clinical masquerader. Mortality due to multiorgan failure is often high even with early recognition and treatment.